India is poised to launch one of the biggest food subsidy programs ever attempted, but some experts say it will fail unless major steps are taken to improve sanitation.

“In the absence of focus on sanitation, what we have is taxpayer-funded diarrhea and little else,” Pavan Srinath, policy research manager at the Takshashila Institution, a think-tank, said of the program that the government says will cost about $20 billion a year.

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The government approved the National Food Security Law last week. As Parliament is in recess, the law is classed as an ordinance, or temporary legislation, until Parliament reconvenes and votes on it at the end of the month or early August. The passing of the law is expected to be a formality.

Under the program, the government will sell very cheap rice, wheat and other grains to around 800 million poor Indians, or around 70% of the population.

In addition to the critics who say the program is misdirected and a bid by the ruling Congress party-led government to win votes, health experts say the subsidies overlook the problem of poor sanitation.

A lack of access to toilets means that hundreds of millions of people defecate in the open in India. As a result, children are exposed to bacterial infections and parasites that can damage the small intestine and reduce or stop its capacity to absorb nutrients needed for growth and development, no matter how much food is consumed.

Unicef says there are 61.7 million stunted children in India, more than anywhere else in the world. The government estimates that around 20% of children under five are wasted, or too thin for their height and 43% are underweight for their age.

In a recent paper in Economic and Political Weekly, Robert Chambers from the University of Sussex in the U.K. and Gregor von Medeazza from Unicef India said the link between sanitation and under-nutrition has been largely overlooked, describing it as a “blind spot.”

Last month, Rural Development Minister Jairam Ramesh was quoted in the media as saying: “I don’t see the same degree of political enthusiasm on sanitation. I think we neglect this at peril… When we talk about sanitation, we can only giggle.”

Gagandeep Kang, professor in the Department of Gastrointestinal Sciences at Christian Medical College in Vellore, is involved in an international study funded by the Bill and Melinda Gates Foundation to look at how pathogens damage children’s guts, leading to malnutrition.

“You can’t argue sanitation alone is going to lead to people not being malnourished. Nor is food alone going to lead to every single child growing fine. It has to be a combination of both of those,” she said.

According to research by Dean Spears, a visiting economist at the Delhi School of Economics, there is less stunting of children in Indian districts with toilets. Improved sanitation meant infant mortality decreased by four per 1,000 and children’s height increased, he said.

The World Health Organization says diarrhea is a leading cause of malnutrition in children under five. More than 800,000 children in that age bracket die every year from diarrhea globally, according to Unicef. A quarter of these deaths happen in India.

A survey from 2011 found that nearly 80% of Indian children with diarrhea did not wash their hands with soap after visiting the toilet.

The challenge the government faces is finding a way to get more Indians to use toilets, which some have said is a culture problem. “The biggest thing about sanitation is individual behavior,” Mr. Srinath said.

“It’s an individual choice. Most people in India don’t want to spend money to build a toilet,” he added.

Atish Patel is a multimedia journalist based in Delhi. You can follow him on Twitter @atishpatel.

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